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Case Management Verification
(Clinical Setting)
I, _____________________________________, certify that I am not currently receiving medical or non-Print Client’s Name
medical case management services through the Ryan White Program or any other provider of HIV Case
Management services.
Client’s Signature Date
I hereby certify that prior to enrollment into the case management program, CAREWare was used to
verify that was not receiving medical or Print Client’s Name
non-medical case management services through the Ryan White Program.
Case Manager/Agency Representative Signature Date
Charlotte TGA Ryan White Program May 2015
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